Abstract
Fibrinogen is crucial for the formation of blood clot and clinical outcomes in major bleeding. Both Thromboelastography (TEG) and Rotational Thromboelastometry (ROTEM) have been increasingly used to diagnose fibrinogen deficiency and guide fibrinogen transfusion in trauma and surgical bleeding patients. We conducted a comprehensive and comparative review on the technologies and clinical applications of two typical functional fibrinogen assays using TEG (FF TEG) and ROTEM (FIBTEM) for assessment of fibrinogen level and deficiency, and prediction of transfusion requirement. Clot strength and firmness of FF TEG and ROTEM FIBTEM were the most used parameters, and their associations with fibrinogen levels as measured by Clauss method ranged from 0 to 0.9 for FF TEG and 0.27 to 0.94 for FIBTEM. A comparison of the interchangeability and clinical performance of the functional fibrinogen assays using the two systems showed that the results were correlated, but are not interchangeable between the two systems. It appears that ROTEM FIBTEM showed better associations with the Clauss method and more clinical use for monitoring fibrinogen deficiency and predicting transfusion requirements including fibrinogen replacement than FF TEG. TEG and ROTEM functional fibrinogen tests play important roles in the diagnosis of fibrinogen-related coagulopathy and guidance of transfusion requirements. Despite the fact that high-quality evidence is still needed, the two systems are likely to remain popular for the hemostatic management of bleeding patients.
Highlights
Fibrinogen is perhaps the most important protein in hemostasis, as the final stage of the coagulation cascade is converted to fibrin by thrombin and cross-linked by factor XIII
A systematic review and meta-analysis of the use of TEG and Rotational Thromboelastometry (ROTEM) in goal-directing treatment with allogeneic blood products in bleeding patients found that the amount of transfused red blood cells, fresh frozen plasma, and bleeding volume was reduced in the TEG- or ROTEM-guided groups compared to the control groups either treated at the clinician’s discretion or based on conventional coagulation tests (CCTs), whereas there were no differences in platelet transfusion and mortality [18]
fibrinogen assays using TEG (FF TEG) K, Alpha showed moderate correlations and gently mixed by inversion five times, with fibrinogen concentration (ρ=-0.46 and 0.40, p
Summary
Fibrinogen is perhaps the most important protein in hemostasis, as the final stage of the coagulation cascade is converted to fibrin by thrombin and cross-linked by factor XIII. Thromboelastography (TEG; Haemonetics Corporation, Haemoscope Division, Nile, Illinois, USA) and Rotational Thromboelastometry (ROTEM; Tem Innovations GmbH, Munich, Germany; succeeded by Instrumentation Laboratory, Bedford, MA, USA) are two point-of-care systems for hemostatic tests in whole blood [7]. Both have been increasingly used to diagnose fibrinogen deficiency [8], predict risk of bleeding and mortality, and guide fibrinogen transfusion in trauma [9], cardiac surgery [10], liver transplantation [11], and postpartum bleeding [12]. A randomized clinical trial has concluded that TEG-guided massive transfusion protocol for severe trauma improved survival compared with that guided by CCTs (i.e., prothrombin time [PT]/international normalized ratio [INR], fibrinogen, and D-dimer) and utilized less plasma and platelet transfusion during the early phase of resuscitation [19]
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